GAO: CMS must take stronger stand on Medicare fraud, overpayments

The U.S. Department of Health & Human Services is leaving billions of dollars on the table by not acting on recommendations from the Government Accountability Office for Medicare oversight, according to a GAO report released Wednesday. In its push for reducing waste, GAO says there are missed opportunities for savings in managing Medicare.

GAO recommended further minimizing improper payments and fraud. Although GAO back in 2007 suggested CMS require contractors to develop automated prepayment controls to identify improper claims, CMS has yet to implement them, although CMS added other controls that flag claims, it said.

In 2010, GAO also recommended CMS designate personnel to identify vulnerabilities to curb improper payments. Although CMS began work on the process, it hasn't written policies or procedures on monitoring actions. GAO last month testified before the Senate Finance Committee, stating that CMS could do more to strengthen provider screening to avoid enrolling fraudsters. GAO also said CMS could improve pre- and postpayment claims reviews to look for suspicious billing patterns more effectively.

In 2008, GAO told CMS to add front-end safeguards to control the rapid spending on advanced imaging services with mechanisms such as prior authorization. CMS hasn't implemented it but does have a demonstration project to assess physicians' use of diagnostic imaging.

CMS's implementation of cutting the number of contractors overseeing Medicare Secondary Payer debt has saved $86 million from 2006 to 2010. In another accepted GAO recommendation, CMS increased oversight of state Medicaid financing arrangement that yielded savings of $3.4 billion from 2007 to 2012, according to the report.

For more information:
- read the GAO summary and report (.pdf)

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